By Maneet Dharia, DDS
A 63-year-old male desired dental implants in areas of his jaw with bone deficiency and missing teeth. Though treated for hypertension and high cholesterol with losartan and atorvastatin, these medical conditions were well controlled, and his overall health was relatively good.
But the patient still carried with him the traumatic experience from the time he’d had teeth removed. Though he wanted to have his missing teeth replaced with implants, he had a fear of dental treatment. This dental anxiety contributed to a delay in seeking treatment—until he found out about dental sedation. With that safe option in mind, he decided to pursue the care necessary to restore his mouth to full function. He accepted his treatment plan and found a suitable companion to accompany and assist him.
His experience began with a pre-sedation workup. The patient was deemed to be ASA II due to his well-controlled systemic disease (2). His airway was assessed and his lungs were auscultated (important because congestion can reduce oxygenation during the appointment). He was determined to be a suitable candidate for dental sedation, and was given post-operative medication prescriptions with clear instructions on their use.
Pre- and post-operative instructions were discussed with the patient and his wife, who agreed to get him home safely once recovered and monitor him for 24 hours. The patient was concerned about not being able to eat all day, so he requested an early morning appointment.
The pre-sedation appointment is very important because it allows the patient to give consent for the dental procedure and review all of the sedation instructions with a clear mind. It is important to have consent in advance of the procedure because the patient will not have a clear mind, due to medications on the day of treatment.
On the day of the appointment, the patient came in NPO, and had used the restroom. (Being NPO is very important to reduce a threat to the patient’s life (1), including avoiding the risk of the patient aspirating vomit.)
The patient was given a combination of zolpidem, clonidine, lorazepam and midazolam in safe and efficacious doses—the clonidine helps to increase sedation and reduce anxiety (3)—and also took a pre-med dose of amoxicillin prior to surgery, along with a chlorhexidine rinse. The patient entered sedation within 30 minutes and, as the patient’s oral sedation took place, an IV was established to continue the sedation via titration of midazolam. The patient had taken his medications as normal the night before, and his high blood pressure was not an issue during the sedation due to his well-controlled medicine use and oral dose of clonidine.
The surgery went well for the patient. Prior to discharge, he completed a test to demonstrate coherence and ensure he was fully recovered. His wife signed him out and agreed that she was capable of taking care of him at home.
The next day, the dental office followed up with the patient to make sure he was doing well. He expressed relief that his appointment had been completed so quickly and he had only scant recollection of the visit.
At a later appointment to remove the sutures, the patient revealed that he wished all dental experiences could be like the one he’d had with sedation.
- Kramer FM. Patient perceptions of the importance of maintaining preoperative NPO status. AANA Journal. 2000 Aug;68(4):321-328.
- BJA: British Journal of Anesthesia, Volume 77, Issue 2, Aug 1996, Pages 217–222, https://doi.org/10.1093/bja/77.2.217
- Kumar, A., Bose, S., Bhattacharya, A., Tandon, O.P. and Kundra, P. (1992), Oral clonidine premedication for elderly patients undergoing intraocular surgery*. Acta Anaesthesiologica Scandinavica, 36: 159-164. doi: 10.1111/j.1399-6576.1992.tb03444.x
Maneet Dharia, DDS is a Los Angeles dentist focused on the prevention of dental problems and educating patients and their families. He received a B.S. in Nutritional Sciences from Michigan State University, and graduated dental school at the University of Michigan. His continuing education studies include IV and Oral Sedation, UCLA Dental Implant Continuum, Cosmetic Fillings, Root canals and Crowns, Sleep Apnea Treatment, Oral Surgery and Tooth Removal including third molars, Invisalign Orthodontics. This article is part of his DOCS Education Fellowship program.